Senior Financial Assistance

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Email

example@example.com

Animals Name

How Long Have You Owned Your Pet?

How Many Other Animals Do You Own?

Other Animals Type, Breed, Age - If Not Applicable Please Indicate as Such

Are All Animals in the Home Spayed/Neutered?

YesNoOther

Are All Animals in the Home Up-To-Date on Vaccines?

YesNoOther

Name of Veterinary Office

Vet's Phone Number

Vet's Email

Is This a Single Person Household or a Two Person Household?

SingleTwoOther

Source of Household Income

Total Household Income - Indicate if Yearly, Monthly, Bi-Weekly, Weekly

Are You Able to Cover the Cost of Expenses in Excess of Potter's Angels Rescues Contribution?

YesNo

If No to Above Please List Other Sources of Assistance and Amounts Provided or Enter N/A.

Comments/Notes

Please Upload Proof of Income - Whichever is Applicable - Previous two pay stubs, SSI(D) stubs, UI Benefits, Previous Years Tax Returns

By signing below I attest to the following:

I attest that all information that I have provided is true to the best of my knowledge.
I understand that completing this application does not guarantee Potter's Angels Rescue will provide me with financial assistance.
I understand that my application must still go through the approval process.
I understand that Potter's Angels Rescue will contact both myself, and the veterinarian that referred me, of the status of my application.
I understand that if assistance is provided it will be paid directly to my veterinarian.
I understand that I may not qualify for more than $500 of assistance in any 12 month period.
I have read and understand the "Financial Assistance for Low-Income Seniors Program Guidelines".
I have read and understand the "Additional Resources for Veterinary Financial Assistance" document.

Signature

Application for Financial Assistance